The present invention relates to an apparatus capable of enabling a practitioner to thread a suture in subcutaneous tissue from a remote access point, to surgical methods facilitated by such an apparatus, and to associated tools useful with the apparatus for performing such surgical methods.
Various surgical methods require the placement of a suture deep inside subcutaneous tissue for the purpose of supporting, severing, ligating, or constricting tissue, vessels, ligaments, nerves or other anatomy or for pulling another device into position defined by the suture pathway. Typically, this necessitates making an incision through the skin and subcutaneous tissue in order to gain sufficient access for deploying the suture directly to the desired location, for example, in an open surgical procedure or for feeding a suture passing instrument with an endoscopic or laparoscopic instrument to a distal location from the initial point of access.
An example of one such procedure, in the field of plastic surgery, is the mid-face lift. As part of this procedure, an incision is made in an inconspicuous location to conceal the incision and to make scarring less obvious. The facial tissue is then separated to achieve sufficient access and mobility of the tissue to permit one or more sutures to be deployed to reattach and/or reposition the tissue into a more aesthetically desirable result. In addition, it is often desirable to anchor ends of the sutures to a rigid structure, for purposes of support. In practice, however, the selection of an anchoring structure which is suitable for fixation, which is accessible, and which can provide an inconspicuous incision, often complicates the procedure and results in a significant distance between the supported tissue and the fixation structure. The can result in a procedure which requires extensive surgery, which can be expensive, which can create significant trauma to the tissue, and which can take a significant amount of time to heal (e.g., a matter of weeks), and may also create sub-optimal aesthetic results.
Various procedures have been attempted to reduce the resulting trauma to a patient, the corresponding expense of the procedure, and the time required for recovery. For example, one attempted procedure has been to use needles to implant a device having barbed profiles capable of engaging subcutaneous tissue at a location remote from the point of access. In practice, however, such barbs have been found to be prone to release after a relatively short period of time, often on the order of a few months. Release of the barbs then allows the engaged tissue to sag.
Other attempted procedures have made use of endoscopes to reduce the size of the accessing incision. However, endoscope-guided suturing devices are bulky mechanisms, and tend to require considerable separation of the tissue layers and the severing of connective fibers in order to pass the instrument from the incision at the anchor location to the intended base of the suture supporting loop, and to surgically release the naturally occurring connective fibers so that the lift will be effective. Moreover, in the case of an endoscopic-guided mid-face lift, significant care and skill are required to avoid rupturing critical branches of the facial nerve as the device traverses a path from the temporal fascia to the intended location. Furthermore, endoscopic suturing devices are limited in the amount of tissue that can be engaged distally to distribute the lifting force, which can make the sutures prone to pull through the tissue (so-called “cheese-wire effect”) over time. Additionally, the endoscopic mid-face lift begins in the temporal fascia in the hairline in order to hide the insertion incision scar and to provide a suitable structure to anchor the sutures. However, this alters the naturally occurring anchor location of the mid-face tissue to a location which is substantially superior and which can result in a lift vector which is long and constrained by other anatomy, which can affect the aesthetics of the lift.
It has therefore remained desirable to provide a minimally invasive technique for redirecting a suture along a desired pathway or to transfer a suture from one internal pathway to another through the use of external manipulation and tactile feel, as well as to achieve an optimum suture deployment vector for a desired procedure, while providing a practitioner with considerable flexibility in the choice of vector and suture configurations and the ability to capture multiple sutures.